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EMORY FAMILY MEDICINE Differential Diagnosis of Chest Pain Susan Schayes M.D., M.P.H.

EMORY FAMILY MEDICINE Differential Diagnosis of Chest Pain Susan Schayes M.D., M.P.H. Division Chief, Emory Family Medicine Emory University School of Medicine. Chest pain. Top 10 reason for admission to hospital on the family medicine service Many admitted for 24-48 hour admission.

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EMORY FAMILY MEDICINE Differential Diagnosis of Chest Pain Susan Schayes M.D., M.P.H.

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  1. EMORY FAMILY MEDICINEDifferential Diagnosis of Chest Pain Susan Schayes M.D., M.P.H. Division Chief, Emory Family Medicine Emory University School of Medicine

  2. Chest pain • Top 10 reason for admission to hospital on the family medicine service • Many admitted for 24-48 hour admission

  3. Chest pain • History is key to DDx- reliability? • Pretest likelihood from patient’s age, gender, character of pain or discomfort and associated risk factors. • Risk factor stratification

  4. Chest pain • Rapid determination in ER if a life threatening process with triage • If likelihood that the patient’s pain is from myocardial ischemia, aortic dissection or pulmonary embolism--a true medical emergency • ABC

  5. Aortic Dissection • •Hx: sudden, severe “ripping” pain in ant chest, may radiate to • back • •Etiology • – HTN • –Trauma (blunt, cath/surgery) • –Pregnancy • –Connective tissue (Marfans, Ehlers-Danlos) • •Clinical: • –HTN, BP both arms not equal, distal pulses diminished, AR murmur, cardiac tamponade, neurologic defecits • –Mortality high • •Diagnosis: • –CXR –wide mediastinum • –CT, TEE, MRI • •Treatment • –Beta blockade (Esmolol/Labetalol) + Nipride • –Type A/Proximal –surgery Type B/Distal -medical

  6. Pulmonary Embolus • •Presentation:, dyspnea/tachypnea, tachycardia, • pleuriticCP/cough +/-hypotension, hemoptysis • •Risk • – surgery/trauma • – obesity, smoking • – oral contraceptives, pregnant/post partum • – malignancy • – immobilization/illness (ICU/stroke/CHF/Pneumonia) • – indwelling central line • •PE: hypoxia/A-a gradient ( although may be Nl), anxious, • RV strain, tachycardia/tachypnea, • •Diagnosis • – ECG S1Q3T3 (<7%) LAB –DDimer(nonspecific); CLINICAL • – CXR –oligemia(Westermark’s sign) infarct (Hampton’s hump) • – CT (PE protocol), V/Q scan, Pulmonary Angiogram • • Treatment ABC • –anticoagulation/thrombolysis, interventional/surgical mgmt

  7. Initial CxRsometimes NORMAL. May show – Collapse, consolidation, small pleural effusion, elevated diaphragm. Westermark sign– Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels, often with a sharp cut off. Plain film radiography Chest X-ray

  8. VQ Scan results Ventilation Perfusion Mismatch

  9. Spiral / MultisliceCT Results Main Pulmonary Artery Ascending Aorta Descending Aorta Rt Pulmonary Artery Lt Pulmonary Artery Thrombus

  10. Differential Diagnosis •Cardiovascular –Angina (unstable, MI) –Aortic dissection –Pericarditis –PE –Pulmonary HTN –AS/HOCM •Pulmonary –Pneumothorax –Pleurisy/Pneumonia –Tumor •Other –Herpes Zoster –Anxiety/functional d/o

  11. •Gastrointestinal –GERD/Esophagitis –Esophageal Spasm –Mallory-Weiss tear –Peptic Ulcer/Gastritis –Pancreatitis –Biliary dz •Musculoskeletal –costochondritis –trauma (rib fx, strain, mets) –cervical disk dz –arthritis of shoulder/spine

  12. Chest pain • TIMI Risk Score (UA/NSTEM)–A risk score (0-7) assigned for patients presenting with unstable angina or non-ST elevation MI. One point is assigned for each of seven clinical variables: • Marker of 14 day risk of death, MI or urgent revascularizaton • Markers 0/1 2 3 4 5 6/7 • 14d risk 4.7% 8.3% 13.2% 19.9% 26.2% 40.9% • The TIMI risk score for unstable angina/non-ST elevation MI, JAMA, 2000

  13. Chest pain • TIMI Risk Score ( UA/NSTEM)– • 1.     Age > 65 years • 2.    > 3 CAD risk factors (FHx, HTN, DM, Active Smoker) • 3.    Known CAD (Stenosis> 50%) • 4.    Aspirin use within last 7 days • 5.    Recent severe angina (> 2 anginal symptoms within 24 hours) • 6.    Elevated Cardiac Markers • 7.    ST segment Deviation > 0.5 mm

  14. Chest pain • TIMI Risk Score (STEMI) [6]– TIMI Risk Score (STEMI) – a risk score (0-14) assigned for patients who present with ST elevation myocardial infarction. The score is the arithmetic sum of point values assigned to each:

  15. Chest pain • TIMI Risk Score (STEMI) [6]– • Age >75 3 • Age 65-74 3 • Diabetes 1 • Hypertension/Angina 1 Systolic bp <100 3 HR > 100 2 Killip class II-IV 2 Weight <67kg 1 Anterior ST elevation or LBBB 1 Time to treat >4 hours 1

  16. Chest pain • Differential diagnosis • Nonpleuritic: Cardiac- Esophageal- Subdiaphramatic Aorta- Skin- MSK structures Mediastinal tumors Psych Mitral Valve Prolapse

  17. Chest pain • Pleuritic Cardiac-Pulmonary-GI- Subdiaphragmatic Skin-MSK structures Collagen Vascular Diseases Psych Familial Mediterranean Fever

  18. Chest pain • Many patients need to be treated as though they have myocardial ischemia, until the diagnostic dilemma is resolved.

  19. Chest pain • 2% of ED patients with Acute MI and another 2% with unstable angina are inadventently discharged after their evaluation • ER overcrowding Annals of Emergency Medicine Dec 2004

  20. Chest Pain Evaluation • Computer data base of 10,057 visits to San Francisco General ED with Dx of CP ‘93-98, age over 35 years. AEM Oct 99 • 9.9% MI, 22.3%unstable angina, 8.5% CHF, 11.7%acute pulmonary process , 1.6%surgical abdomen,0.3% P.E..

  21. Chest pain evaluation • Community Chest Pain Center, AJC April 99 • I year follow up of patients • 59% undefined noncardiac, 15% no workup diagnosis,11% GI, 7% MSK, 5% Anxiety, 3% other • Risk stratification

  22. Chest Pain Evaluation • AJM, Oct 1996 ,Montreal Heart Institute • 25% of patients with chest pain met DSM IIIR criteria for panic disorder.( 108/441 ) • 57% of panic disorder patients ( 64/108 ) had criteria for one or more current AXIS disorder. • 98% of the panic patients were not recognized by attending ED cardiologists

  23. Panic disorder • 4 of the following during an attack • SOB, dizziness, palpitations, tachycardia, trembling, sweating ,choking, nausea or abdominal distress, depersonalization or derealization, paresthesias, flushing, chest pain, fear of dying, fear of going crazy

  24. Low risk group • Pleuritic chest pain • pain localized with finger • reproducible pain • brief pain lasting seconds • constant pain>24 hours • No other risk factors know • normal EKG

  25. Intermediate Risk Group • Diabetes with atypical symptoms-no other risk factors • Atypical symptoms with 2 or more risk factors • Atypical symptoms with peripheral vascular disease • Nonspecific EKGs

  26. High Risk Group • Chest or L arm discomfort as chief symptom reproducing past angina, known Hx of CAD, including MI • Transient mitral regurg, hypotension, diaphoresis, pulmonary edema, rales • New transient ST-segment deviation or T wave deviation, with symptoms • ACC/AHA 2002 Guideline update for the management of patients with unstable angina and non-ST segment elevation myocardial infarction

  27. Positive : Negative • Heart and esophagus share the same spinal cord sensor innervation, myocardial ischemia and esophageal pain are sometimes indistinguishable

  28. Angina clues • Usually substernal and transient • Often brought on by exercise and relieved by rest or nitrates • May be provoked by a large meal, or exertion • Typically builds in intensity from several minutes to 30 mins, then wanes and disappears over several minutes.

  29. Unstable angina clues • Features that mark instability: new onset angina, occurring more frequently at lower workloads, rest angina, angina that wakes you up, angina not responsive to nitrates, angina associated with severe nausea, weakness, dyspnea, sweating, palpitations, syncope, or pulmonary edema.

  30. Myocardial ischemia • Located typically in the lower substernal area with radiation to either or both arms. L>R • May radiate to the anterior aspect of the neck or jaw • ischemic pain is usually described as heavy, constricting, pressure, crushing. • Deep pain and commonly assoc. with sweating, dyspnea, nausea andhiccupping

  31. Chest pain • Most admissions will require a “rule out process” • Many of the economic and medical resources used to evaluate patients with chest pain are unnecessary • Formulate workup based on careful history, physical examination and ancillary testing

  32. Chest pain • Tincture of time is a diagnostic modality • Listen, look and reassess again and again serially your patient ! • Your patient is not the computer! Reassess the human Not the computer

  33. Limiting Exposure • Both the choice, timing and interpretation of noninvasive cardiac testing and other testing will depend on the perceived urgency and instability of the clinical scenario

  34. Diagnostic testing CK - peaks at 12-14 hrs, normalizes in 2-3 days CK MB- quickly rises typically dbling every 3-6 hours Troponin I- peaks at 12-18 hours, rise within 3-6 hrs of chest pain, remains elevated for 5-7 days Myoglobin-peaks 4-5 hrs

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